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© All Wales Special Interest Group Special Oral Health Care
ALL WALES SPECIAL INTEREST GROUP
SPECIAL ORAL HEALTH CARE
GRWP DIDDORDEB ARBENNIG CYMRU GYFAN GOFAL IECHYD
ANGHENION GENEUOL ARBENNIG
Oral Nutritional Supplementation
and Oral Health
Recommendations for health care
professionals to reduce the impact of
Oral Nutritional Supplementation (ONS),
sip feeding and nutritional advice
on dental health
October 2009
www.sigwales.orgwww.sigwales.orgwww.sigwales.orgwww.sigwales.org
The All Wales The All Wales The All Wales The All Wales SSSSpecial pecial pecial pecial IIIInterest nterest nterest nterest GGGGroup (SIG) for roup (SIG) for roup (SIG) for roup (SIG) for Special Special Special Special Oral HealthOral HealthOral HealthOral Health
CareCareCareCare is a gis a gis a gis a group of Special Care Dentistsroup of Special Care Dentistsroup of Special Care Dentistsroup of Special Care Dentists, Specialists in Special Care , Specialists in Special Care , Specialists in Special Care , Specialists in Special Care
DentistryDentistryDentistryDentistry and Dental Care and Dental Care and Dental Care and Dental Care PPPProfessionalsrofessionalsrofessionalsrofessionals who advisewho advisewho advisewho advise the the the the Clinical Clinical Clinical Clinical
Directors of Directors of Directors of Directors of Community Dental Services Community Dental Services Community Dental Services Community Dental Services in in in in WalesWalesWalesWales
2
CONTENTCONTENTCONTENTCONTENTSSSS
PagePagePagePage
Oral Nutritional Supplementation (Sip Feeds and Snacks) and Oral Health 3
1. Reasons for Malnutrition (under-nutrition) 4
2. Nutritional Assessment 5
3. Body Weight 5
4. Management of Malnutrition 5
4.1 Oral Nutritional Support 6
4.2 Sip Feed and other Supplements 6
5. Recommendations 7
Case Study 8
Recommendations for local protocols and Oral Nutritional 9
Supplementation Care
Training Issues for Prescribers of Oral Nutritional 9
Supplementation and the Dental Team
References 10
Appendix 1 - Types of Sip Feed 11
Appendix 2 - Oral Health Risk Assessment 12
Appendix 3 - Oral Care Pathway for Nutritional Supplements 13
Appendix 4 - Oral Health Preventative flowchart for those Prescribed 14
Oral Nutritional Supplementation
Appendix 5 - Oral Health Advice for Patients on Food Supplements 15
Appendix 6 - Sip Feed Guidelines Leaflet 16
Appendix 7 - Nutritional Supplements and Good Oral Health Advice 17
Sheet -
3
Oral Nutritional Supplementation
(Sip Feeds and Snacks) and Oral Health
Malnutrition predisposes to disease, delays in recovery from illness, adversely
affects body function, well-being and clinical outcome, and is often
unrecognised in the clinical setting. Within dentistry there is a paucity of
evidence based research to support the concerns of the dental profession about
the cariogenic effects of oral nutritional supplements, especially carbohydrate
rich sip feeds for children and adults who are underweight or malnourished.
The Scientific Basis of Oral Health Education provides a wealth of evidence
that links the frequency of eating snacks that contain sugar and the increase in
incidence of dental caries (decay) (Levine & Stillman-Lowe, 2009).
This report highlights the current advice regarding the treatment of
malnutrition and makes recommendations for preventive oral health care for
health professionals prescribing oral nutritional supplements to reduce the
potentially negative impact of food supplements on dental health.
The British Association for Parenteral and Enteral Nutrition (BAPEN) in the
MUST Report estimates that one in seven adults in the UK aged 65 years and
over is affected by malnutrition (BAPEN, 2003). Estimates for malnutrition are
higher in those who are institutionalised; for residents in care homes, this is
estimated to be between 20%-50% (BAPEN, 2003). Guidelines on
‘Nutritional Support in Adults’ (NCCAC, 2006) commissioned by the National
Institute for Health and Clinical Excellence (NICE, 2006) state that it is essential
that nutritional screening be carried out to identify individuals who are
malnourished and that the cause for poor nutritional status should be identified
and treated. The Guidelines also considered appropriate methods of feeding
people who are still capable of deriving at least some of their nutritional
requirements by conventional feeding, and/or have difficulty in swallowing.
Oral nutrition support is the provision of dietary advice to patients on how to
increase overall nutritional intake, and the modification of food and fluid by:
Fortifying food with protein, carbohydrate and/or fat, plus minerals and
vitamins and/or
The provision of snacks and/or oral nutritional supplements as extra
nutrition to regular meals and/or
Changing meal patterns that include frequency of nutritional intake.
4
1. 1. 1. 1. Reasons for MalnutritionReasons for MalnutritionReasons for MalnutritionReasons for Malnutrition (under(under(under(under----nutrition) nutrition) nutrition) nutrition)
All healthcare professionals must be aware of the signs of malnutrition
and refer accordingly. Factors contributing to disease related
malnutrition summarised in ‘Nutrition support in adults’ (NCCAC,
2006; NICE, 2006) are reproduced in Table 1.
Table 1 Factors contributing to disease related malnutritionTable 1 Factors contributing to disease related malnutritionTable 1 Factors contributing to disease related malnutritionTable 1 Factors contributing to disease related malnutrition
ProblemProblemProblemProblem CauseCauseCauseCause
Impaired intakeImpaired intakeImpaired intakeImpaired intake Poor appetite due to illness (major & common cause);
• pain/ nausea when eating;
• depression/anxiety;
• food aversion;
• medication;
• drug addiction.
Inability to eat:
• diminished consciousness;
• confusion;
• weakness or arthritis in arms or hands;
• dysphagia;
• vomiting;
• painful oral problems including poor dentition;
• restrictions imposed by surgery or investigations.
Lack of food:
• poverty;
• poor quality diet at home, hospital or in care
homes;
• problems with shopping or cooking.
Impaired digestion Impaired digestion Impaired digestion Impaired digestion
and/or absorption and/or absorption and/or absorption and/or absorption
Medical and surgical problems affecting the stomach,
intestine, pancreas or liver.
Altered Altered Altered Altered
requirementsrequirementsrequirementsrequirements
Increased or changed metabolic demands related to
illness, surgery, organ dysfunction, or treatment.
Excess nutrient Excess nutrient Excess nutrient Excess nutrient
losseslosseslosseslosses
Gastrointestinal losses:
• vomiting
• diarrhoea
• fistulae
• stomas
Losses from nasogastric tube and other drains
Other losses e.g. skin exudates from burns.
5
2. 2. 2. 2. Nutritional AssessmentNutritional AssessmentNutritional AssessmentNutritional Assessment
When malnutrition is suspected, an assessment using the ‘Malnutrition
Universal Screening Tool’ (MUST) (King et al 2004; BAPEN 2003) is
recommended.
3. 3. 3. 3. Body WeightBody WeightBody WeightBody Weight
The assessment of nutritional risk for malnutrition by measuring changes
in body weight is an important indicator of nutritional status. There are
many methods of assessment including height and weight (Body Mass
Index [BMI]), waist circumference and muscle mass.
Identification of malnourishment is summarised in ‘Nutrition Support in
Adults’ (NCCAC, 2006 ; NICE, 2006):
Rapid unintended weight loss greater than 10% within the last 3-6
months.
BMI of less than 18.5 kg/m2
BMI of less than 20kg/m2 and unintentional weight loss greater
than 5% within the last 3-6months.
Eaten little or nothing for more than 5days/or not likely to eat little
or nothing for the next 5 days or longer.
Have a poor absorptive capacity and /or have high nutrition losses
/or increased nutritional needs.
4. 4. 4. 4. Management of MalnutritionManagement of MalnutritionManagement of MalnutritionManagement of Malnutrition
The guidelines emphasise that healthcare professionals should ensure
that nutritional care provides:-
Food and fluid of adequate quantity and quality in an environment
conducive to eating
Appropriate support, for example modified eating aids, for people
who can potentially chew and swallow but are unable to feed
themselves
That all those who require nutritional support receive coordinated
care from a multidisciplinary team.
Nutritional support may take several forms:-
Improve energy and nutrient intake from foods
Fortify foods
Sip feed and other forms of supplementation
Enteral and parenteral nutrition.
6
4.1 4.1 4.1 4.1 Oral Nutritional SupportOral Nutritional SupportOral Nutritional SupportOral Nutritional Support
In the first instance, individuals are advised to increase frequency
of food consumption to every 2-3 hours by having a small meal,
snack or milk based drink as indicated in the ‘Good Food Leaflet’
(Thomas 2008). Energy rich foods that include jams and
preserves, cakes, biscuits, pastries and chocolate to increase calorie
intake are encouraged.
Nourishing sip style feeds such as milkshakes, fruit juices, yoghurts
and soups are also recommended. These are often advised to be
taken ‘between meals’, although Delivering Better Oral Health
recommends that dietary supplements for children and those with
special needs should be given at meal times to reduce the risk of
dental caries (DoH, 2007).
4.2 4.2 4.2 4.2 Sip Feed and Other SupplementsSip Feed and Other SupplementsSip Feed and Other SupplementsSip Feed and Other Supplements
‘Sip feed’ is a term which is often used to describe oral nutritional
supplements (ONS) that are given to increase nutritional intake.
There are many prescribable supplements that are nutritionally
complete and can be ‘sipped’ throughout the day. They are very
expensive and should not be prescribed without the involvement
of a dietitian to ensure all other methods of increased nutritional
intake have been explored.
Oral supplements (frequently prescribed for sip feeding) are
regarded as an addition to food and not a food substitute unless
the patient cannot face food on the occasional day for some
reason. Available dietary carbohydrates in most ONS are derived
from sugars, principally glucose, fructose and galactose
(monosaccharides) and sucrose, lactose and maltose (disaccharides)
as well as starches (polysaccharides) [Appendix 1].
Many malnourished children and adults are prescribed ONS if
insufficient energy cannot be achieved by ordinary food and drink
intake. These supplements may show a small improvement in
clinical outcomes but the evidence in a Cochrane Systematic
Review is uncertain (Baldwin & Weekes, 2008). Up to three
cartons maybe prescribed per day resulting in an increase in 250-
900 calories per day. As wastage is an important factor,
compliance must be monitored as well as weight, and once
appetite has returned and normal eating patterns resumed, the
supplement must be reduced and then discontinued.
7
5. 5. 5. 5. RecommendationsRecommendationsRecommendationsRecommendations
The All Wales Medicines Strategy Group (AWMSG, 2006) identified
concerns about the use and misuse of ONS and recommended the
development of:-
A multidisciplinary community nutrition team approach
Patient information leaflets
Training in sip feeding for healthcare professionals
Strategies to improve nutritional intake from food
Oral Nutrition Integrated Care Pathway.
The Quality Improvement Toolkit for Oral Nutritional Support (Sip
Feeds) (NPHS Wales, 2009) has compiled a checklist to ensure the
provision of quality care when prescribing ONS. Although the checklist
identifies oral problems and poor dentition as risk factors for reduced
nutritional intake, it does not include an Oral Health Risk Assessment
(OHRA).
The inclusion of an OHRA would identify factors that may be affecting
the individual’s ability to eat and highlight the need for a dental referral
to treat symptoms, and provide oral health preventive advice if
nutritional support/sip feeding is prescribed as recommended in
Fundamentals of Care (WAG, 2003) and Essence of Care (DoH, 2001).
The OHRA Appendix 2 may be adapted and completed by the
individual, healthcare professionals or care staff.
The development of local multidisciplinary oral nutrition care pathways
must include a link to dental teams (Appendix 3). An OHRA would
alert the health care professionals or care staff to follow an oral care
pathway that comprises oral health preventive regimes for those
children and adults who have their own natural teeth to reduce the risk
for dental decay (Appendicies 4 & 5). Adults and children receiving
ONS are advised to seek an appointment with their dentists as soon as
possible. For those who require more specialist advice and dental care
provision, the local Community Dental Service should be contacted.
With information and support through training, all healthcare
professionals will understand the association between poor oral health
and malnutrition. Any individual being prescribed ONS should be
provided with oral health prevention information and professional
intervention involving fluoride supplementation should they have their
own natural teeth. Examples of patient information leaflets for
prescribers or dispensers of ONS such as dietitians, general medical
practitioners, hospital doctors and pharmacists are found in Appendices
6 & 7.
8
By following SIG’s recommendations for vulnerable adults and children
who are malnourished, and prescribed ONS, the risk of increased dental
decay from frequent consumption of drinks, snacks or sip feeds will be
reduced.
The The The The All Wales Special Interest Group/Special Oral Health CareAll Wales Special Interest Group/Special Oral Health CareAll Wales Special Interest Group/Special Oral Health CareAll Wales Special Interest Group/Special Oral Health Care
recommendsrecommendsrecommendsrecommends::::
Raising awareness of the increased risk of dental caries associated
with oral nutritional supplements and increased frequency of high
sugar content meals, snacks and drinks.
Training for nutritional care teams and prescribers of oral nutritional
supplementation on the impact of oral nutritional supplements and
other dietary advice on dental health
Local protocols that must include oral health care information
Oral Nutrition Care pathway involving multidisciplinary community
teams with links to appropriate dental teams
The use of an Oral Health Risk Assessment for appropriate and
timely routine referrals to the dental team
Patient information leaflets describing the need for oral health care
that ensures all children and adults who are dentate be given
preventive oral health care advice
Access to appropriate dental care services (Community Dental
Services, Community /Salaried Dental Service or General Dental
Services).
The Oral Nutritional Care Pathway and local protocols will advise when
referral to a dental team is indicated by utilising an Oral Health Risk
Assessment tool.
CASE STUDYCASE STUDYCASE STUDYCASE STUDY
AAAAnnnn 86 year old 86 year old 86 year old 86 year old woman woman woman woman with dementia with dementia with dementia with dementia who resides in a nursing home has been who resides in a nursing home has been who resides in a nursing home has been who resides in a nursing home has been
losing weight for sometime losing weight for sometime losing weight for sometime losing weight for sometime resulting in resulting in resulting in resulting in a BMI of 17. a BMI of 17. a BMI of 17. a BMI of 17. TTTThe Community he Community he Community he Community DietiDietiDietiDietittttianianianian
assessed the paassessed the paassessed the paassessed the patient and advised tient and advised tient and advised tient and advised a a a a more appetising menu and more appetising menu and more appetising menu and more appetising menu and ssssoft diet that oft diet that oft diet that oft diet that
includedincludedincludedincluded an increase in smallan increase in smallan increase in smallan increase in small,,,, betweenbetweenbetweenbetween mealmealmealmeal snacks that contain sugar. snacks that contain sugar. snacks that contain sugar. snacks that contain sugar. SheSheSheShe also also also also
recrecrecrecommended that a carbohydrate nutritionalommended that a carbohydrate nutritionalommended that a carbohydrate nutritionalommended that a carbohydrate nutritional oraloraloraloral feed be left by the patient’s feed be left by the patient’s feed be left by the patient’s feed be left by the patient’s
side side side side and that she should and that she should and that she should and that she should be encouragbe encouragbe encouragbe encouraged to siped to siped to siped to sip throughout the day. throughout the day. throughout the day. throughout the day. The woman The woman The woman The woman
has her own natural teeth that she struggles to brush on a daily basis. has her own natural teeth that she struggles to brush on a daily basis. has her own natural teeth that she struggles to brush on a daily basis. has her own natural teeth that she struggles to brush on a daily basis. The The The The
nursing home has a robust oral health care nursing home has a robust oral health care nursing home has a robust oral health care nursing home has a robust oral health care protocol protocol protocol protocol that highlights the need to that highlights the need to that highlights the need to that highlights the need to
contactcontactcontactcontact the local community dental teamthe local community dental teamthe local community dental teamthe local community dental team when nutritional swhen nutritional swhen nutritional swhen nutritional supplementation is upplementation is upplementation is upplementation is
advisedadvisedadvisedadvised.... The The The The dental dental dental dental team discover that the patient has a team discover that the patient has a team discover that the patient has a team discover that the patient has a painful abscess that painful abscess that painful abscess that painful abscess that
may have contributed to her may have contributed to her may have contributed to her may have contributed to her reduced oral intake and subsequent reduced oral intake and subsequent reduced oral intake and subsequent reduced oral intake and subsequent weight lossweight lossweight lossweight loss. . . .
Treatment is provided for the dental infection Treatment is provided for the dental infection Treatment is provided for the dental infection Treatment is provided for the dental infection and aand aand aand an oral care plan is drawn up n oral care plan is drawn up n oral care plan is drawn up n oral care plan is drawn up
wwwwhich includes extra fluoride supplementation as well as hich includes extra fluoride supplementation as well as hich includes extra fluoride supplementation as well as hich includes extra fluoride supplementation as well as staff staff staff staff training training training training provided provided provided provided
by by by by the the the the OOOOral ral ral ral HHHHealth ealth ealth ealth PPPPromotion team romotion team romotion team romotion team in order to encourage and assist the in order to encourage and assist the in order to encourage and assist the in order to encourage and assist the
resident with resident with resident with resident with oral health careoral health careoral health careoral health care....
9
Recommendations for local protocols and Oral Nutritional SupplementatioRecommendations for local protocols and Oral Nutritional SupplementatioRecommendations for local protocols and Oral Nutritional SupplementatioRecommendations for local protocols and Oral Nutritional Supplementation Care n Care n Care n Care
PathwaysPathwaysPathwaysPathways
1) Development of dental services which are acceptable, accessible and specialise in
care for vulnerable people in residential care especially care homes.
2) Oral Risk Assessment criteria that identify risk factors for oral health to be included
in the overall assessment/malnutrition Care plan in order to: Identify individual oral care needs and develop a Personal Oral Care Plan
Provide appropriate preventive advice, fluoride supplementation and oral hygiene
equipment
Identify need for and access to dental services.
3) Provision of oral health advice and support for children and adults who are
malnourished and require oral nutritional supplementation.
4) Provision of oral health education and promotion for health care professionals and
carers of people who are malnourished and the individuals themselves that address Oral health needs
Oral hygiene techniques and fluoride for prevention of caries and periodontal
disease
Oral health care problems associated with high sugar containing foods and oral
nutritional support (sip feeds).
5) Establish specialist dental services that link into care pathways to ensure: Access to emergency care
Appropriate specialist dental services especially for those that require special care
dentistry (dysphagia, dementia, brain injury etc)
Support for health professionals and carers in oral care
Procedures for continuity of dental care on discharge from hospital and
rehabilitation
The workforce has appropriate skills mix.
Training issues for pTraining issues for pTraining issues for pTraining issues for prescribers of Oral Nutritional Supplementation and the dental rescribers of Oral Nutritional Supplementation and the dental rescribers of Oral Nutritional Supplementation and the dental rescribers of Oral Nutritional Supplementation and the dental
teamteamteamteam
1) Health care professionals should have knowledge and understanding of:-
Scientific basis for oral health and disease
Oral risk assessment criteria and tools for assessment
Risk factors for oral health and oral side effects of nutritional supplementation
Current oral care practices appropriate to individual needs
Practical oral care techniques that encourages fluoride supplementation
Oral hygiene aids to support clients with oral hygiene
Eligibility criteria for exemption for the cost of NHS dental care
Availability and access to local dental services.
2) Dental team should have formal training in:-
The effects of malnutrition and its impact on oral health
Identification of patients requiring more specialised dental care services
Oral health promotion and preventive regimes for this client group
Dental care management Legislation around incapacity to consent for care.
10
ReferencesReferencesReferencesReferences
All Wales Medicines Strategy Group (AWMSG). Recommendations regarding the prescribing and supply of oral supplementation. 2006
Baldwin, C., Weekes, C.E., Dietary advice for illness-related malnutrition in adults. Cochrane Database Systematic Review 2008 Jan 23;(1): CD002008
British Association for Parenteral and Enteral Feeding (BAPEN). The ‘MUST’ Report: National screening of adults: a multidisciplinary responsibility. 2003. www.bapen.org.uk
British National Formulary: 56 September 2008.
Department of Health. 2001. The Essence of Care: patient focussed benchmarking for health care practitioners. London, DoH.
www.doh.gov.uk/essenceofcare/index/htm
Department of Health & British Association for the Study of Community
Dentistry. Delivering better oral health: an evidence based tool-kit for prevention. 2007. www.dh.gov.uk/publications
Griffiths J, Boyle S. Chapter 6 Oral Assessment in Holistic Oral Care a guide for Health Professionals (2005) 2nd Ed. Pub Stephen Hancocks Ltd.
Griffiths J, Lewis D. Guidelines for the oral care of patients who are
dependent, dysphagic or critically ill. J Disabil Oral Health 2002 3333: 30-33.
Levine R, Stillman-Lowe C. Scientific Basis of Oral Health Education. 2009. 6th
edition. Pub British Dental Journal. www.bda.org
National Public Health Service for Wales, Quality Improvement Toolkit for Oral Nutritional Support (Sip Feeds) Feb 2009. www.nphs.wales.nhs.uk
National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. NCCAC, London. www.rcseng.ac.uk
National Institute for Health and Clinical Excellence. Clinical Guideline 32. Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. February 2006. www.nice.org.uk
Thomas D. Good Food First: Getting the best from nutritional supplements. Neath and Port Talbot LHB report. July 2008
Welsh Assembly Government. Fundamentals of Care: Guidance for Health and Social Care Staff. 2003. www.wales.nhs.uk/documenta/booklet-e.pdf
11
AppendixAppendixAppendixAppendix 1111
Types Types Types Types oooof Sip Feedsf Sip Feedsf Sip Feedsf Sip Feeds
Milk based, ready to drinkMilk based, ready to drinkMilk based, ready to drinkMilk based, ready to drink
Milk based, ready to drink products (supplied as 175-200ml tetrapaks) are the most commonly used sip feeds.
They are nutritionally complete and provide 1.0-1.7 kcals/ml. Although generally used as food supplements
they can be used short term as the sole source of nutrition if required.
Examples: Ensure Plus, Fortisip, Fortifresh. Clinutren 1.5, Enrich Plus, Complan ready-to-drink, Resource shake.
Milk Based, fibre enrichedMilk Based, fibre enrichedMilk Based, fibre enrichedMilk Based, fibre enriched
Fibre enriched, milk based feeds are nutritionally complete and ready to drink. They have an added fibre blend
(2.5-4.5g fibre /pack), thus they mimic the normal diet. They are useful for patients with constipation or
physical difficulties and for those taking opioids.
Examples: Entera Fibre plus, Enrich Plus, Fortisip Multifibre.
Fruit juice based Fruit juice based Fruit juice based Fruit juice based
Fruit juice based feeds are not nutritionally complete because they are fat free and therefore cannot be used as
a sole source of nutrition. However they provide 1.25-1.5 kcal/ml and contain protein, vitamins and minerals.
They are an alternative supplement for patients who dislike or cannot tolerate milk based feeds.
Examples: Enlive, Fortijuice, Provide Xtra, Clinutren Fruit.
Powdered supplementsPowdered supplementsPowdered supplementsPowdered supplements
Powdered supplements are not nutritionally complete. Some are prescribable (e.g. Scandishake) but others (e.g.
Build up and Complan) are not and can be bought over the counter. They can be reconstituted with fresh milk
or water and are available in sweet and savoury flavours. Products such as Neutral Build-up and Complan can
also be added to foods such as soups, puddings and mashed potato.
Examples: Neutral build-up, Complan.
Semi solid supplementsSemi solid supplementsSemi solid supplementsSemi solid supplements
Semi solid supplements provide 1.25-1.5 kcal/g; they are frequently used for dysphagic patients who are at risk
of aspirating fluids. These are not suitable for use as the sole source of nutrition
Examples: Formance, Fortipudding, Clinutren Dessert.
High protein supplementsHigh protein supplementsHigh protein supplementsHigh protein supplements
High protein supplements are not suitable as a sole source of nutrition. They can be useful in patients with
burns or fistulae because of the high protein content.
Examples: Fortimel (liquid), Protein Forte, Maxisorb Powder.
Energy supplementsEnergy supplementsEnergy supplementsEnergy supplements
Energy supplements are not suitable as a sole source of nutrition. They mainly contain carbohydrate and
provide no protein. They are available in powder or liquid form. Energy supplements can be used to increase
calorie intake in patients who cannot tolerate other sip feeds, or, in renal patients whose fluid intake needs to
be restricted. The liquid products can be diluted and used as a squash or added to puddings. The powders are
high in calories and can be incorporated into drinks soups and puddings without affecting taste.
Examples: Polycal, Maxijul, Caloreen.
The British National Formulary (2008) adds a note of caution to prescribers of supplements.
ReferencesReferencesReferencesReferences
Oral nutritional support (part2): nutritional supplements. MeRec Bulletin Volume 9, Number
9, 1998.
Murphy P. Enteral feeds explained. The Pharmaceutical Journal 2001; 267267267267: 297-300.
Foods included in this Appendix may contain cariogenic sugars and patients should be advised to takeFoods included in this Appendix may contain cariogenic sugars and patients should be advised to takeFoods included in this Appendix may contain cariogenic sugars and patients should be advised to takeFoods included in this Appendix may contain cariogenic sugars and patients should be advised to take
appropriate oral hygiene measures appropriate oral hygiene measures appropriate oral hygiene measures appropriate oral hygiene measures
12
Appendix Appendix Appendix Appendix 2222
Oral Health Risk AssessmentOral Health Risk AssessmentOral Health Risk AssessmentOral Health Risk Assessment Oral health risk assessment by health care professionals and carers provides a tool for
opportunistic identification of people who have oral/dental problems which affect their
nutritional intake and which may lead to the need for oral nutrition supplementation. This Oral
Health Risk Assessment may be adapted by wards, care homes and community teams as part of
nutritional supplementation pathway. It should be used in collaboration with local/specialist
dental teams order to facilitate access to an appropriate dental service.
1. Does the patient have natural teeth?1. Does the patient have natural teeth?1. Does the patient have natural teeth?1. Does the patient have natural teeth?
� NONONONO � YESYESYESYES
Complete oral care plan
and/or refer to dental
team
� Don’t KnowDon’t KnowDon’t KnowDon’t Know Check with patient
2. Will the patient require nutritional 2. Will the patient require nutritional 2. Will the patient require nutritional 2. Will the patient require nutritional
supplementation for more than 3 supplementation for more than 3 supplementation for more than 3 supplementation for more than 3
weeks?weeks?weeks?weeks?
� NONONONO
� YESYESYESYES Complete oral care plan
and refer immediately to dental team for fluoride
supplementation advice
� Don’t KnowDon’t KnowDon’t KnowDon’t Know Check with prescriber
3.3.3.3. Does the patient have any Does the patient have any Does the patient have any Does the patient have any
problems? (Pain, discomfort, problems? (Pain, discomfort, problems? (Pain, discomfort, problems? (Pain, discomfort,
difficulty eating, denture problems, difficulty eating, denture problems, difficulty eating, denture problems, difficulty eating, denture problems,
ulcers, dry mouth, halitosis) If YES ulcers, dry mouth, halitosis) If YES ulcers, dry mouth, halitosis) If YES ulcers, dry mouth, halitosis) If YES
describe the problem.describe the problem.describe the problem.describe the problem.
� NONONONO
� YESYESYESYES Complete oral care plan
and/or refer to dental
team
� Don’Don’Don’Don’t Knowt Knowt Knowt Know Check with patient.
Observe for possible oral
pain or discomfort
4. Is the client taking any medication? 4. Is the client taking any medication? 4. Is the client taking any medication? 4. Is the client taking any medication?
(Check the BNF for any oral side (Check the BNF for any oral side (Check the BNF for any oral side (Check the BNF for any oral side
effects)effects)effects)effects)
� NONONONO
� YESYESYESYES Complete oral care plan
and/or refer to dental
team
� Don’t KnowDon’t KnowDon’t KnowDon’t Know Check with patient / drug
chart
5. Does the patient require assistance 5. Does the patient require assistance 5. Does the patient require assistance 5. Does the patient require assistance
for oral health care for oral health care for oral health care for oral health care � NONONONO
� YESYESYESYES Complete oral care plan
� Don’t KnowDon’t KnowDon’t KnowDon’t Know Assess the patient
6. Is urgent dental treatment required?6. Is urgent dental treatment required?6. Is urgent dental treatment required?6. Is urgent dental treatment required? � NONONONO � YESYESYESYES Referral to dental team
� Don’t KnowDon’t KnowDon’t KnowDon’t Know Check with dental team
7. Does the patient visit a dentist 7. Does the patient visit a dentist 7. Does the patient visit a dentist 7. Does the patient visit a dentist
regularly? If YES record name and regularly? If YES record name and regularly? If YES record name and regularly? If YES record name and
addressaddressaddressaddress
� YESYESYESYES � NONONONO Check with patient and
refer to dental team
� Don’t KnowDon’t KnowDon’t KnowDon’t Know Check with patient
A response in the highlighted A response in the highlighted A response in the highlighted A response in the highlighted areas signifies a need for further areas signifies a need for further areas signifies a need for further areas signifies a need for further
investigation or actioninvestigation or actioninvestigation or actioninvestigation or action.
Adapted from Griffiths J, Boyle S. Chapter 6 Oral Assessment in Holistic Oral Care a guide for Health Professionals (2005) 2nd Ed. Pub Stephen Hancocks Ltd.
13
Appendix Appendix Appendix Appendix 3333
Oral Care Pathway foOral Care Pathway foOral Care Pathway foOral Care Pathway for Nutritional Supplementsr Nutritional Supplementsr Nutritional Supplementsr Nutritional Supplements
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SSSSSSSSEEEEEEEERRRRRRRRVVVVVVVVIIIIIIIICCCCCCCCEEEEEEEE
PPPPPPPPRRRRRRRRIIIIIIIIMMMMMMMMAAAAAAAARRRRRRRRYYYYYYYY
CCCCCCCCAAAAAAAARRRRRRRREEEEEEEE
DDDDDDDDEEEEEEEENNNNNNNNTTTTTTTTIIIIIIIISSSSSSSSTTTTTTTT
RRRRRRRREEEEEEEEFFFFFFFFEEEEEEEERRRRRRRRRRRRRRRRAAAAAAAALLLLLLLL TTTTTTTTOOOOOOOO::::::::--------
SSSSSSSSPPPPPPPPEEEEEEEECCCCCCCCIIIIIIIIAAAAAAAALLLLLLLLIIIIIIIISSSSSSSSTTTTTTTT IIIIIIIINNNNNNNN
SSSSSSSSPPPPPPPPEEEEEEEECCCCCCCCIIIIIIIIAAAAAAAALLLLLLLL CCCCCCCCAAAAAAAARRRRRRRREEEEEEEE
DDDDDDDDEEEEEEEENNNNNNNNTTTTTTTTIIIIIIIISSSSSSSSTTTTTTTTRRRRRRRRYYYYYYYY
FEEDING FEEDING FEEDING FEEDING TEAMSTEAMSTEAMSTEAMS
NURSESNURSESNURSESNURSES
GENERAL GENERAL GENERAL GENERAL MEDICAL MEDICAL MEDICAL MEDICAL PRACTICEPRACTICEPRACTICEPRACTICE
CONSULTANTS CONSULTANTS CONSULTANTS CONSULTANTS AND HEALTH AND HEALTH AND HEALTH AND HEALTH
CARE WORKERSCARE WORKERSCARE WORKERSCARE WORKERS
KEY All these professionals should ensure referral directly to the Dental
Team
DIETIDIETIDIETIDIETICIANCIANCIANCIAN
CARECARECARECARE TEAMSTEAMSTEAMSTEAMS
PPPPPPPPAAAAAAAATTTTTTTTIIIIIIIIEEEEEEEENNNNNNNNTTTTTTTT
FFFFFFFFAAAAAAAAMMMMMMMMIIIIIIIILLLLLLLLYYYYYYYY
CCCCCCCCAAAAAAAARRRRRRRREEEEEEEERRRRRRRR
RRRRRRRREEEEEEEEFFFFFFFFEEEEEEEERRRRRRRRRRRRRRRRAAAAAAAALLLLLLLL TTTTTTTTOOOOOOOO::::::::--------
SSSSSSSSPPPPPPPPEEEEEEEECCCCCCCCIIIIIIIIAAAAAAAALLLLLLLLIIIIIIIISSSSSSSSTTTTTTTT IIIIIIIINNNNNNNN
PPPPPPPPAAAAAAAAEEEEEEEEDDDDDDDDIIIIIIIIAAAAAAAATTTTTTTTRRRRRRRRIIIIIIIICCCCCCCC
DDDDDDDDEEEEEEEENNNNNNNNTTTTTTTTIIIIIIIISSSSSSSSTTTTTTTTRRRRRRRRYYYYYYYY
14
Prescribe high fluoride
toothpaste e.g.
Duraphat 5000/2800 ,
high fluoride
mouthwash or fluoride
varnish applications
Frequent sipping and
snacks will cause
plaque to build up
on denture surfaces
and tongue with
potential to cause
thrush infections.
Follow denture
cleaning protocol.
Clean denture
ridges/gums and
tongue gently using
soft toothbrush
Frequent sipping
and snacks will
cause plaque to
build up on
tongue with
potential to
cause thrush
infections.
Clean gums
and tongue
gently using soft
toothbrush
Appendix Appendix Appendix Appendix 4444
ORAL HEALTH PREVENTATIVE NEEDS FOR THOSE PRESCRIBED ORAL HEALTH PREVENTATIVE NEEDS FOR THOSE PRESCRIBED ORAL HEALTH PREVENTATIVE NEEDS FOR THOSE PRESCRIBED ORAL HEALTH PREVENTATIVE NEEDS FOR THOSE PRESCRIBED
ORAL NUTRITIONAL SUPPLEMENTATIONORAL NUTRITIONAL SUPPLEMENTATIONORAL NUTRITIONAL SUPPLEMENTATIONORAL NUTRITIONAL SUPPLEMENTATION
Any natural teeth present?
How long will patient be taking oral supplementation? If more than 3 weeks, oral health risk assessment has to be
completed and reviewed in one month
YES
Dentures
worn?
YES
Consider long term
prescription of Duraphat
5000 even after sip
feeds/snacks cease
HHIIGGHH RRIISSKK OOFF
DDEENNTTAALL DDEECCAAYY
Additional Risk
factors:
1) Dry mouth – frequent sips of water or saliva
substitutes. 2 ) Dexterity compromised
– use electric toothbrush
3) Totally dependent e.g.
physical disability or
dementia- the carer
should assist in brushing.
4) Gums receded –
consider regular
application of fluoride
varnish to root surfaces
by dental team or high
fluoride toothpaste.
5) Dentures present –
careful cleaning
required
(All may be present in same
patient).
ORAL ASSESSMENT ON ADMISSION
NB In all cases; be aware of any potential swallow problems and If present follow dysphagia guidelines for mouthcare, taking care to avoid risk of aspiration of toothpaste/foam/ during
toothbrushing
Dentures
worn?
NO
RISK of
dental caries
NO
15
Appendix Appendix Appendix Appendix 5555
Oral Health Advice for Patients on Food SupplementsOral Health Advice for Patients on Food SupplementsOral Health Advice for Patients on Food SupplementsOral Health Advice for Patients on Food Supplements
Oral nutritional supplements are usually prescribed for those children and
adults who are malnourished and under weight. Food supplementation often
consists of foods, drinks and sip feeds containing increased carbohydrate
content. Frequent snacking or ‘sipping’ of these supplements throughout the
day increases the chances of dental decay in people who have their own
natural teeth. Whilst it is important to follow nutritional advice given by
professionals, the potentially harmful effects to the teeth caused by using these
food supplements can be minimised. The following programme of prevention
is recommended:-
Brushing with fluoride toothpaste at least twice a day. Assistance may be
required if the patient is unable to manage this themselves.
Patients should spit out toothpaste after brushing and not rinse their
mouth with water afterwards to maximise the effect of the fluoride.
Use toothpaste that contains at least 1450ppm Fluoride.
Toothpaste paste containing 2500-5000 ppm Fluoride is recommended
in preventing decay but can only be used on prescription from a dentist.
Fluoride varnish can only be applied by the dental team.
Frequent sips of water throughout the day and rinsing with water after
using the supplement will help.
For patients who have a very dry mouth, artificial saliva can be
prescribed.
The use of a straw can help to minimise the contact of the food
supplement with the tooth surface.
Due to the increased possibility of dental decay, regular dental checks
are important.
The Dental Team will be able to give further advice on prevention.
16
Appendix Appendix Appendix Appendix 6666
SIP FEED GUIDELINSIP FEED GUIDELINSIP FEED GUIDELINSIP FEED GUIDELINES LEAFLETES LEAFLETES LEAFLETES LEAFLET
Front and Back of leaflet shown below:-
Middle Section of leaflet shown below:-
17
Appendix Appendix Appendix Appendix 7777
NUTRITIONAL SUPPLEMENTS AND NUTRITIONAL SUPPLEMENTS AND NUTRITIONAL SUPPLEMENTS AND NUTRITIONAL SUPPLEMENTS AND
GOOD ORAL HEALTH ADVICE SHEETGOOD ORAL HEALTH ADVICE SHEETGOOD ORAL HEALTH ADVICE SHEETGOOD ORAL HEALTH ADVICE SHEET
Front and Back of advice sheet shown below:-
Middle Section of advice sheet shown below:-
18
All Wales Special Interest GroupAll Wales Special Interest GroupAll Wales Special Interest GroupAll Wales Special Interest Group / Special Oral Health Care/ Special Oral Health Care/ Special Oral Health Care/ Special Oral Health Care
CCCContributors ontributors ontributors ontributors to these guidelinesto these guidelinesto these guidelinesto these guidelines::::
Sue Greening
Janet Griffiths
Liz Hunt
Vicki Jones
Chandi Joshi
Susan Payne
Michele Seager
Enquiries to:
Dr Vicki Jones
Chair All Wales Special Interest Group
Dental Department
Ringland Health Centre
Ringland
Newport NP9 9PS
vicki.jones@wales.nhs.uk
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